Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality

  • Authors:
    • Minoru Tomizawa
    • Fuminobu Shinozaki
    • Rumiko Hasegawa
    • Yoshinori Shirai
    • Yasufumi Motoyoshi
    • Takao Sugiyama
    • Shigenori Yamamoto
    • Naoki Ishige
  • View Affiliations

  • Published online on: March 9, 2017     https://doi.org/10.3892/etm.2017.4209
  • Pages: 1932-1936
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Abstract

The utility and limitations of abdominal ultrasonography (US) were retrospectively evaluated as a first‑line diagnostic imaging modality in patients with abdominal pain. Hospital records from patients subjected to abdominal US as a first-line diagnostic imaging examination at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) from April 2010 to April 2015 were analyzed. Only those patients who underwent abdominal US to diagnose abdominal symptoms were included in the present study. All patients with prior diagnostic imaging examination findings were excluded from the study in order to reduce bias of results. The analyzed patients included 39 males with an average (mean ± standard deviation) age of 65.8±18.8 years and 37 females with an average age of 53.7±19.3 years. Diagnosis with abdominal US was in agreement with the final diagnosis in 66 of the 76 patients. Final diagnosis of symptoms by abdominal US was not successful in the remaining 10 patients who required further investigation. Acute cholangitis, acute cholecystitis, acute pancreatitis, acute appendicitis, colonic diverticulitis and spleen rupture were correctly diagnosed. Different types of cancer, including colorectal cancer, were also successfully diagnosed. Bile duct cancer and sigmoid colon volvulus could not be diagnosed by abdominal US due to the presence of intestinal gas. Abnormal findings were detected using abdominal US, but the diagnosis required additional consultation with gynecologists. Abdominal US was suitable for patients with abdominal symptoms. It is recommended that patients undergo further diagnostic imaging or consultation with gynecologists when large gas bubbles are present or gynecological conditions are suspected.

Introduction

Abdominal pain is one of the most common symptoms prompting patients to visit hospitals. Among such individuals, a number of patients have serious diseases and require subsequent hospitalization or surgery. Diagnosis may consist of acute appendicitis, intestinal obstruction and other serious conditions such as bowel necrosis and intestinal volvulus (1). Correct and prompt diagnosis is essential for the appropriate management of patients. Diagnosis of patients with abdominal pain is primarily determined by imaging techniques, such as radiography, abdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) (2). Among these, abdominal US is a non-invasive procedure, which is readily available at most hospitals even during off-hours (weekends, nights and holidays) and may be performed at the bedside (3).

Abdominal US is indispensable for the diagnosis of diseases in the abdominal cavity in patients with abdominal symptoms (4,5). In addition, abdominal US is also useful for the diagnosis of solid organ conditions, including acute cholangitis, acute cholecystitis and acute pancreatitis (68). Abdominal US is also useful in the diagnosis of bowel disease based on pathological findings (9,10). Diagnostic criteria with abdominal US have been established for acute appendicitis and colonic diverticulitis (1114) and colorectal cancer may be diagnosed with abdominal US (15). In numerous cases, patients are diagnosed by a combination of laboratory data and diagnostic imaging findings based on symptoms and physical examination. With regards to diagnostic imaging, CT is recommended as the first-line procedure (16); however, CT is not readily available during off-h at the majority of hospitals. In these cases, abdominal US is the first-line procedure performed.

On the basis of the aforementioned considerations, the current study retrospectively analyzed the records of patients who underwent abdominal US as a first-line diagnostic imaging procedure in order to evaluate its utility and limitations in determining the diagnosis of patients presenting with abdominal symptoms.

Materials and methods

Patients

Medical records were retrospectively analyzed for 76 patients who were subjected to abdominal US as the first-line diagnostic imaging modality at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) from April 2010 to April 2015. Abdominal US was performed at the time of consultation or during off-hours (weeknights, weekends and holidays). Recruited patients were restricted to those in which abdominal US was performed as a first diagnostic approach in order to evaluate the diagnostic performance solely from abdominal US without any potentially confounding information from other diagnostic imaging procedures. Thus, patients were excluded when abdominal US was performed following another diagnostic imaging procedures, such as radiography, CT or MRI because the sonographer may have been informed of the findings obtained. The analyzed patients included 39 males with an average (mean ± standard deviation) age of 65.8±18.8 years and 37 females with an average age of 53.7±19.3 years.

Patients were hospitalized or referred to a different hospital based on the diagnosis obtained by abdominal US, the results of blood examinations, clinical findings or diagnostic imaging following abdominal US. The National Hospital Organization Shimoshizu Hospital does not have a department of gynecology. Therefore, patients were referred to another hospital for gynecological consultation. The referred hospitals were National Hospital Organization Chiba Medical Center (Chiba, Japan) and Seirei Sakura Citizen Hospital (Sakura, Japan). During off-hours, the management of patients was determined on the basis of abdominal US and clinical symptoms. The present study was approved by the Ethics Committee of the National Hospital Organization Shimoshizu Hospital. It was not considered a clinical trial since abdominal US was performed as a part of routine clinical practice. Written informed consent for inclusion in the study was waived. Patient records/information was anonymized and de-identified prior to analysis.

Abdominal US

Abdominal US was performed by Senior Fellows of the Japan Society of Ultrasonics in Medicine (Tokyo, Japan; http://www.jsum.or.jp/jsum-e/index.html) using a SSA-700A US system (Toshiba Medical Systems Corporation, Ohtawara, Japan) with a 3.75-MHz curved-array probe (PVT-375BT; Toshiba Medical Systems Corporation) or an 8.0-MHz linear-array probe (PLT-805AT; Toshiba Medical Systems Corporation).

Diagnostic criteria of diseases

Acute cholangitis is defined as inflammation due to the obstruction of a bile duct (6). Findings detectable by abdominal US include bile duct dilatation and evidence of its etiology, such as stricture, stones or stent (6). In the present study, in the absence of these findings, acute cholangitis was not diagnosed by abdominal US, but was based on a combination of symptoms including systemic inflammation and cholestasis (6). Acute cholecystitis was diagnosed by a combination of local and systemic signs of inflammation (7). Abdominal US supported the diagnosis with findings of distension, wall thickening and sludge in the gallbladder (7). More specifically, the finding of a sonographic Murphy sign was considered the most reliable because it is considered to suggest inflammation of the gallbladder (17).

Acute pancreatitis is typically diagnosed as abdominal pain, elevated serum amylase and swelling of the pancreas by diagnostic imaging (18). In the current study, acute pancreatitis was diagnosed when abdominal US revealed a swollen pancreas, fluid collection and inflammation of adjacent organs. Acute diverticulitis was diagnosed as diverticulum with thickened wall and high echo from the surrounding tissue (Fig. 1A) (12). Acute appendicitis was diagnosed as swollen appendix with a diameter >10 mm, and thickened wall (Fig. 1B) (13,14).

Results

Successful diagnosis of patients

Initial diagnosis with abdominal US was in agreement with the final diagnosis in 66 patients. For the remaining 10 patients, the diagnosis obtained from abdominal US differed from the final diagnosis. To investigate the performance and limitations of abdominal US, patients were divided into two groups. The first included patients in whom abdominal US diagnosis agreed with the final diagnosis (Table I) and the other included patients whose initial abdominal US diagnosis differed from the final diagnosis (Table II).

Table I.

Diseases successfully diagnosed with abdominal ultrasonography.

Table I.

Diseases successfully diagnosed with abdominal ultrasonography.

DiagnosisNumber of patientsNumber of off-houra patients
Acute cholangitis15  3
Acute appendicitis11  9
Acute cholecystitis  7  0
Acute pancreatitis  7  4
Enteritis  7  4
Colonic diverticulitis  5  3
Ileus  2  2
Colorectal cancer  2  1
Hepatocellular carcinoma  2  0
Pancreatic cancer  2  0
Bile duct cancer  2  1
Bowel perforation  2  2
Spleen rupture  1  0
Upper gastrointestinal bleeding  1  1
Total6630

a Weeknights, weekends and holidays.

Table II.

List of misdiagnosed patients and speculated causes of misdiagnosis following abdominal ultrasound.

Table II.

List of misdiagnosed patients and speculated causes of misdiagnosis following abdominal ultrasound.

Patient numberGenderAge (years)Final diagnosisCause of misdiagnosisConsultation or off-hour
  1F49Acute cholangitisBile duct diameter within normal rangeC
  2M69Bile duct cancer, acute cholangitisBile duct cancer not detected due to gasO
  3M88Sigmoid colon volvulusDifficult to examine due to presence of massive gas bubblesO
  4F87Acute appendicitisAppendix not detectedO
  5M39Intestinal anisakiasisAnisakiasis not detectedO
  6F89Duodena UlcerTentatively diagnosed as acute cholecystitis due to a positive sonographic Murphy signC
  7M53Spontaneous hemoperitoneumNature of ascites not examined with USO
  8F40Recurrence of cervical cancerPresence of a huge mass in the pelvis of unknown originO
  9F48Left ovarian torsionTorsion not diagnosed by USC
10F57Inflammation of uterusInflammation of the uterus not diagnosedC

[i] F, female; M, male; O, off-hour (weeknights, weekends, and holidays); C, consultation; US, ultrasound.

Colorectal cancer and spleen rupture

Solid organ diseases, including acute cholangitis, acute cholecystitis and acute pancreatitis, were correctly diagnosed by abdominal US. Intestinal diseases, including acute appendicitis and colonic diverticulitis, were also correctly diagnosed. Abdominal US was useful for the diagnosis of various types of cancer, including hepatocellular carcinoma, pancreatic cancer, and colorectal cancer (Fig. 2A). Colorectal cancer findings included irregular shaped wall thickening and loss of stratification, also referred to as the ‘pseudokidney’ sign (15). Critical conditions, such as rupture of the spleen, were also successfully diagnosed with abdominal US (Fig. 2B). Fluid in the abdominal cavity and high echo in the spleen suggested bleeding and damaging lesions, respectively (19). A total of 30 patients were admitted outside of regular working h and were subjected to abdominal US. They were correctly diagnosed without being subjected to CT or other diagnostic imaging procedures. These results clearly indicate that abdominal US is useful for the diagnosis of patients presenting with abdominal symptoms specifically during off-hours.

Unsuccessful diagnosis of patients

Table II summarizes data from those patients who were misdiagnosed by abdominal US and the potential reasons for misdiagnosis. These patients were subjected to additional diagnostic imaging procedures and were hospitalized for treatment because their conditions suggested the necessity of further management. Two patients were referred to another hospital for gynecological consultation. All patients described in Table II were appropriately managed, according to their condition.

One major cause of misdiagnosis was intestinal gas

Gas over the site of the disease made the examination difficult to execute. Gas over the bile duct (patient 2) hindered the detection of bile duct cancer. Gas in the sigmoid colon made the examination difficult for patient 3.

Unsuccessful diagnosis of acute appendicitis and duodenal ulcer

A diagnosis of acute appendicitis was hampered when it was not possible to detect the appendix (patient 4; Fig. 3A) (20).

A sonographic Murphy sign markedly suggests acute cholecystitis when abdominal US findings include distension and wall thickening of the gallbladder (17). Since the duodenum is close to the gallbladder, the tenderness perceived in duodenal ulcer may occasionally resemble a sonographic Murphy sign (patient 6; Fig. 3B).

Unsuccessful diagnosis of gynecological diseases

A major difficulty in successful diagnosis with abdominal US was the presence of gynecological disorders. It was not difficult to detect a mass in the pelvis (patient 8) or a cystic lesion in the ovary (patient 9; Fig. 4A), however it was difficult to diagnose the site or organ of the original lesion, or relative torsion. The abdominal US clearly illustrated ascites and weakened peristalsis of the sigmoid colon (patient 10; Fig. 4B), but the correct diagnosis required subsequent referral to a gynecologist. Thus, these results suggested that patients should be referred for gynecological consultation when the abdominal US indicates abnormal findings in the pelvis, particularly in the ovary and uterus.

Discussion

The presence of gas bubbles makes abdominal US difficult to perform (21). Large amounts of gases arise due to perforation and obstruction of the bowel (22,23). In the current study, bile duct cancer and sigmoid colon volvulus were not diagnosed using abdominal US due to the presence of intestinal gas. Sigmoid colon volvulus requires prompt diagnosis followed by surgical or endoscopic treatment (24). An upside down U-shaped loop of dilated bowel is a typical radiological finding (25). With regards to abdominal US, findings specific to sigmoid colon volvulus have not been reported (26). Abdominal US is not, therefore, suitable for the diagnosis of sigmoid colon volvulus. It is recommended that patients should be subjected to radiography and CT when sigmoid colon volvulus is suspected (27).

The diagnosis of acute appendicitis with abdominal US is challenging when the appendix is unable to be visualized (20). In such cases, a large amount of fluid, phlegmon and pericecal inflammatory fat changes are clear indications for the diagnosis of acute appendicitis (20). In the present study, fluid and high echo tissues were detected (Fig. 3A) and these findings suggested acute appendicitis. However, it was not possible to exclude the diagnosis of colonic diverticulitis or peritonitis. It was concluded that acute appendicitis is difficult to diagnose without the direct observation of the appendix.

Abdominal US is useful for gynecologists in the diagnosis of gynecological emergencies (28). Abnormal findings in the pelvis were detected in the current study, although a precise diagnosis was delayed since patients had to be referred to a gynecologist at a different institution for consultation. Among patients in the present study, ovarian torsion was the most critical condition. Ovarian torsion is diagnosed based on clinical symptoms, abdominal US, CT, and MRI (29). Color Doppler US reveals absent or diminished central venous flow in patients with ovarian torsion (5). However, a diagnosis of ovarian torsion is difficult to achieve (29). A previous report, in addition to the results from the patients in the current study, has suggested that gynecological diseases are difficult to correctly diagnose with abdominal US alone (28). It is recommended that a patient should be promptly referred to a gynecologist if an emergency condition is suspected.

One of the limitations of the present study was the relatively small number of patients examined. The number of patients was limited as the study was restricted to patients subjected to abdominal US as the first diagnostic imaging method. The initial aim of the present study was to evaluate the diagnostic performance of first-line abdominal US for patients presenting with abdominal symptoms. If information from the other diagnostic imaging examinations was available prior to abdominal US, this information may have interfere with the overall outcome of the abdominal US.

In the present study, performing an abdominal US was suitable for the correct diagnosis of patients presenting with abdominal symptoms. CT is sensitive, but requires exposure to radiation; abdominal US reduces the necessity of CT, and lowers the exposure (30). It is recommended that patients should undergo further diagnostic imaging examinations when large gas bubbles are observed (31). It is also recommended that patients should be referred to a gynecologist when gynecological diseases are suspected.

In conclusion, abdominal US was suitable for the diagnosis of patients with abdominal symptoms. It is recommended that further diagnostic imaging be performed for patients with a large gas bubbles and that patients be referred to a gynecologist when gynecological diseases are suspected.

References

1 

Paduszynska K, Celnik A and Pomorski L: Patients subject to surgery due to acute abdominal disorders during the period between 2001–2004. Pol Przegl Chir. 84:488–494. 2012.PubMed/NCBI

2 

Hayes R: Abdominal pain: General imaging strategies. Eur Radiol. 14:(Suppl 4). L123–L137. 2004. View Article : Google Scholar : PubMed/NCBI

3 

Rozycki GS, Cava RA and Tchorz KM: Surgeon-performed ultrasound imaging in acute surgical disorders. Curr Probl Surg. 38:141–212. 2001. View Article : Google Scholar : PubMed/NCBI

4 

Puylaert JB, van der Zant FM and Rijke AM: Sonography and the acute abdomen: Practical considerations. AJR Am J Roentgenol. 168:179–186. 1997. View Article : Google Scholar : PubMed/NCBI

5 

Birnbaum BA and Jeffrey RB Jr: CT and sonographic evaluation of acute right lower quadrant abdominal pain. AJR Am J Roentgenol. 170:361–371. 1998. View Article : Google Scholar : PubMed/NCBI

6 

Kiriyama S, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Yokoe M, et al: New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 19:548–556. 2012. View Article : Google Scholar : PubMed/NCBI

7 

Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, et al: New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 19:578–585. 2012. View Article : Google Scholar : PubMed/NCBI

8 

Scaglione M, Casciani E, Pinto A, Andreoli C, De Vargas M and Gualdi GF: Imaging assessment of acute pancreatitis: A review. Semin Ultrasound CT MR. 29:322–340. 2008. View Article : Google Scholar : PubMed/NCBI

9 

Maturen KE, Wasnik AP, Kamaya A, Dillman JR, Kaza RK, Pandya A and Maheshwary RK: Ultrasound imaging of bowel pathology: Technique and keys to diagnosis in the acute abdomen. AJR Am J Roentgenol. 197:W1067–W1075. 2011. View Article : Google Scholar : PubMed/NCBI

10 

Puylaert JB: Ultrasound of acute GI tract conditions. Eur Radiol. 11:1867–1877. 2001. View Article : Google Scholar : PubMed/NCBI

11 

Karul M, Berliner C, Keller S, Tsui TY and Yamamura J: Imaging of appendicitis in adults. Rofo. 186:551–558. 2014. View Article : Google Scholar : PubMed/NCBI

12 

Puylaert JB: Ultrasound of colon diverticulitis. Dig Dis. 30:56–59. 2012. View Article : Google Scholar : PubMed/NCBI

13 

Ooms HW, Koumans RK, Ho Kang, You PJ and Puylaert JB: Ultrasonography in the diagnosis of acute appendicitis. Br J Surg. 78:315–318. 1991. View Article : Google Scholar : PubMed/NCBI

14 

Rodgers PM and Verma R: Transabdominal ultrasound for bowel evaluation. Radiol Clin North Am. 51:133–148. 2013. View Article : Google Scholar : PubMed/NCBI

15 

Tomizawa M, Shinozaki F, Hasegawa R, Fugo K, Shirai Y, Ichiki N, Sugiyama T, Yamamoto S, Sueishi M and Yoshida T: Screening ultrasonography is useful for the diagnosis of gastric and colorectal cancer. Hepatogastroenterology. 60:517–521. 2013.PubMed/NCBI

16 

Stoker J, van Randen A, Laméris W and Boermeester MA: Imaging patients with acute abdominal pain. Radiology. 253:31–46. 2009. View Article : Google Scholar : PubMed/NCBI

17 

Myrianthefs P, Evodia E, Vlachou I, Petrocheilou G, Gavala A, Pappa M, Baltopoulos G and Karakitsos D: Is routine ultrasound examination of the gallbladder justified in critical care patients? Crit Care Res Pract. 2012:5656172012.PubMed/NCBI

18 

Wu BU and Banks PA: Clinical management of patients with acute pancreatitis. Gastroenterology. 144:1272–1281. 2013. View Article : Google Scholar : PubMed/NCBI

19 

Korner M, Krötz MM, Degenhart C, Pfeifer KJ, Reiser MF and Linsenmaier U: Current role of emergency US in patients with major trauma. Radiographics. 28:225–242. 2008. View Article : Google Scholar : PubMed/NCBI

20 

Estey A, Poonai N and Lim R: Appendix not seen: The predictive value of secondary inflammatory sonographic signs. Pediatr Emerg Care. 29:435–439. 2013. View Article : Google Scholar : PubMed/NCBI

21 

Hoffmann B, Nurnberg D and Westergaard MC: Focus on abnormal air: Diagnostic ultrasonography for the acute abdomen. Eur J Emerg Med. 19:284–291. 2012. View Article : Google Scholar : PubMed/NCBI

22 

Grassi R, Romano S, Pinto A and Romano L: Gastro-duodenal perforations: Conventional plain film, US and CT findings in 166 consecutive patients. Eur J Radiol. 50:30–36. 2004. View Article : Google Scholar : PubMed/NCBI

23 

Hucl T: Acute GI obstruction. Best Pract Res Clin Gastroenterol. 27:691–707. 2013. View Article : Google Scholar : PubMed/NCBI

24 

Yeo HL and Lee SW: Colorectal emergencies: Review and controversies in the management of large bowel obstruction. J Gastrointest Surg. 17:2007–2012. 2013. View Article : Google Scholar : PubMed/NCBI

25 

James B and Kelly B: The abdominal radiograph. Ulster Med J. 82:179–187. 2013.PubMed/NCBI

26 

Lim JH, Ko YT, Lee DH, Lee HW and Lim JW: Determining the site and causes of colonic obstruction with sonography. AJR Am J Roentgenol. 163:1113–1117. 1994. View Article : Google Scholar : PubMed/NCBI

27 

Gingold D and Murrell Z: Management of colonic volvulus. Clin Colon Rectal Surg. 25:236–244. 2012. View Article : Google Scholar : PubMed/NCBI

28 

Popowski T, Huchon C, Fathallah K, Falissard B, Dumont A and Fauconnier A: Impact of accreditation training for residents on sonographic quality in gynecologic emergencies. J Ultrasound Med. 34:829–835. 2015. View Article : Google Scholar : PubMed/NCBI

29 

Gerscovich EO, Corwin MT, Sekhon S, Runner GJ and Gandour-Edwards RF: Sonographic appearance of adnexal torsion, correlation with other imaging modalities, and clinical history. Ultrasound Q. 30:49–55. 2014. View Article : Google Scholar : PubMed/NCBI

30 

Lameris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, ten Hove W, van Leeuwen MS, van Keulen EM, Dijkgraaf MG, et al: Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: Diagnostic accuracy study. BMJ. 338:b24312009. View Article : Google Scholar : PubMed/NCBI

31 

Farina R, Catalano O, Stavolo C, Sandomenico F, Petrillo A and Romano L: Emergency radiology. Radiol Med. 120:73–84. 2015. View Article : Google Scholar : PubMed/NCBI

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Volume 13 Issue 5

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Spandidos Publications style
Tomizawa M, Shinozaki F, Hasegawa R, Shirai Y, Motoyoshi Y, Sugiyama T, Yamamoto S and Ishige N: Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality. Exp Ther Med 13: 1932-1936, 2017
APA
Tomizawa, M., Shinozaki, F., Hasegawa, R., Shirai, Y., Motoyoshi, Y., Sugiyama, T. ... Ishige, N. (2017). Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality. Experimental and Therapeutic Medicine, 13, 1932-1936. https://doi.org/10.3892/etm.2017.4209
MLA
Tomizawa, M., Shinozaki, F., Hasegawa, R., Shirai, Y., Motoyoshi, Y., Sugiyama, T., Yamamoto, S., Ishige, N."Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality". Experimental and Therapeutic Medicine 13.5 (2017): 1932-1936.
Chicago
Tomizawa, M., Shinozaki, F., Hasegawa, R., Shirai, Y., Motoyoshi, Y., Sugiyama, T., Yamamoto, S., Ishige, N."Abdominal ultrasonography for patients with abdominal pain as a first-line diagnostic imaging modality". Experimental and Therapeutic Medicine 13, no. 5 (2017): 1932-1936. https://doi.org/10.3892/etm.2017.4209